|
Demonstrate Use Home INR Mon G0248
|
Professional
|
$186.00
|
|
|
Service Code
|
HCPCS G0248
|
| Hospital Charge Code |
6178135
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.84 |
| Max. Negotiated Rate |
$255.26 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Aetna Managed Medicare |
$92.82
|
| Rate for Payer: Anthem Medicare Advantage |
$92.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$92.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$92.82
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.82
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$218.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$218.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$92.82
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: Quartz Medicare Advantage |
$92.82
|
| Rate for Payer: The Alliance Commercial |
$255.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$92.82
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$162.44
|
|
|
DEMONSTRATE USE HOME INR MON - G0248
|
Facility
OP
|
$71.00
|
|
|
Service Code
|
HCPCS G0248
|
| Hospital Charge Code |
6081628
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$34.08 |
| Max. Negotiated Rate |
$486.06 |
| Rate for Payer: Aetna Commercial |
$63.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.06
|
| Rate for Payer: Aetna Managed Medicare |
$130.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.08
|
| Rate for Payer: Anthem Medicare Advantage |
$130.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.66
|
| Rate for Payer: Cash Price |
$21.30
|
| Rate for Payer: Cash Price |
$21.30
|
| Rate for Payer: Cigna Commercial |
$65.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.66
|
| Rate for Payer: Health EOS Commercial |
$63.19
|
| Rate for Payer: HFN Commercial |
$65.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$486.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.66
|
| Rate for Payer: Multiplan Commercial |
$56.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.99
|
| Rate for Payer: Preferred Network Access Commercial |
$65.32
|
| Rate for Payer: Quartz Beloit One Network |
$34.79
|
| Rate for Payer: Quartz Commercial |
$46.15
|
| Rate for Payer: Quartz Medicare Advantage |
$130.66
|
| Rate for Payer: The Alliance Commercial |
$419.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.66
|
| Rate for Payer: United Healthcare PPO |
$53.25
|
| Rate for Payer: WEA Trust Commercial |
$39.05
|
| Rate for Payer: Wellcare Medicare |
$130.66
|
| Rate for Payer: WPS Commercial |
$52.59
|
|
|
DEMONSTRATE USE HOME INR MON - G0248
|
Facility
IP
|
$71.00
|
|
|
Service Code
|
HCPCS G0248
|
| Hospital Charge Code |
6081628
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$34.79 |
| Max. Negotiated Rate |
$65.32 |
| Rate for Payer: Aetna Commercial |
$63.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.63
|
| Rate for Payer: Cash Price |
$21.30
|
| Rate for Payer: Cigna Commercial |
$65.32
|
| Rate for Payer: Health EOS Commercial |
$63.19
|
| Rate for Payer: HFN Commercial |
$65.32
|
| Rate for Payer: Multiplan Commercial |
$56.80
|
| Rate for Payer: NAPHCARE Commercial |
$42.60
|
| Rate for Payer: Preferred Network Access Commercial |
$65.32
|
| Rate for Payer: Quartz Beloit One Network |
$34.79
|
| Rate for Payer: Quartz Commercial |
$42.60
|
| Rate for Payer: WEA Trust Commercial |
$39.05
|
| Rate for Payer: WPS Commercial |
$52.59
|
|
|
Denali Vena Cava Filter-Femoral
|
Facility
OP
|
$6,585.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4528620
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,843.80 |
| Max. Negotiated Rate |
$6,058.20 |
| Rate for Payer: Aetna Commercial |
$5,926.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,663.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,843.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,280.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,292.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,160.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,490.05
|
| Rate for Payer: Cash Price |
$1,975.50
|
| Rate for Payer: Cigna Commercial |
$6,058.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,684.97
|
| Rate for Payer: Health EOS Commercial |
$5,860.65
|
| Rate for Payer: HFN Commercial |
$6,058.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,938.75
|
| Rate for Payer: Multiplan Commercial |
$5,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,951.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,058.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,226.65
|
| Rate for Payer: Quartz Commercial |
$4,280.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,951.00
|
| Rate for Payer: WEA Trust Commercial |
$3,621.75
|
| Rate for Payer: WPS Commercial |
$4,877.51
|
|
|
Denali Vena Cava Filter-Femoral
|
Facility
IP
|
$6,585.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4528620
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,226.65 |
| Max. Negotiated Rate |
$6,058.20 |
| Rate for Payer: Aetna Commercial |
$5,926.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,490.05
|
| Rate for Payer: Cash Price |
$1,975.50
|
| Rate for Payer: Cigna Commercial |
$6,058.20
|
| Rate for Payer: Health EOS Commercial |
$5,860.65
|
| Rate for Payer: HFN Commercial |
$6,058.20
|
| Rate for Payer: Multiplan Commercial |
$5,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,951.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,058.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,226.65
|
| Rate for Payer: Quartz Commercial |
$3,951.00
|
| Rate for Payer: WEA Trust Commercial |
$3,621.75
|
| Rate for Payer: WPS Commercial |
$4,877.51
|
|
|
Denali Vena Cava Filter-Jugular
|
Facility
IP
|
$6,340.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4528619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,106.60 |
| Max. Negotiated Rate |
$5,832.80 |
| Rate for Payer: Aetna Commercial |
$5,706.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.20
|
| Rate for Payer: Cash Price |
$1,902.00
|
| Rate for Payer: Cigna Commercial |
$5,832.80
|
| Rate for Payer: Health EOS Commercial |
$5,642.60
|
| Rate for Payer: HFN Commercial |
$5,832.80
|
| Rate for Payer: Multiplan Commercial |
$5,072.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,804.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.60
|
| Rate for Payer: Quartz Commercial |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$3,487.00
|
| Rate for Payer: WPS Commercial |
$4,696.04
|
|
|
Denali Vena Cava Filter-Jugular
|
Facility
OP
|
$6,340.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4528619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.20 |
| Max. Negotiated Rate |
$5,832.80 |
| Rate for Payer: Aetna Commercial |
$5,706.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,775.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,121.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,170.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,043.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.20
|
| Rate for Payer: Cash Price |
$1,902.00
|
| Rate for Payer: Cigna Commercial |
$5,832.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,547.86
|
| Rate for Payer: Health EOS Commercial |
$5,642.60
|
| Rate for Payer: HFN Commercial |
$5,832.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,755.00
|
| Rate for Payer: Multiplan Commercial |
$5,072.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,804.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.60
|
| Rate for Payer: Quartz Commercial |
$4,121.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$3,487.00
|
| Rate for Payer: WPS Commercial |
$4,696.04
|
|
|
Dengue Fever Antibodies (IgG, IgM)
|
Professional
|
$147.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
4392573
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$139.65 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Medicare Advantage |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.88
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.88
|
| Rate for Payer: Health EOS Commercial |
$133.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.88
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$139.65
|
| Rate for Payer: Quartz Beloit One Network |
$64.68
|
| Rate for Payer: Quartz Commercial |
$83.79
|
| Rate for Payer: Quartz Medicare Advantage |
$12.88
|
| Rate for Payer: The Alliance Commercial |
$50.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.88
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$56.67
|
|
|
Dengue Fever Antibodies (IgG, IgM)
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
4392573
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$588.00 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.38
|
| Rate for Payer: Anthem Medicare Advantage |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.88
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.88
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.88
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.32
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$12.88
|
| Rate for Payer: The Alliance Commercial |
$588.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.88
|
| Rate for Payer: United Healthcare PPO |
$110.25
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: Wellcare Medicare |
$12.88
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Dengue Fever Antibodies (IgG, IgM)
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
4392573
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Dengue Fever Antibodies IgG, IgM
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
4392804
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.38
|
| Rate for Payer: Anthem Medicare Advantage |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.88
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.88
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.88
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$19.32
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12.88
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.88
|
| Rate for Payer: United Healthcare PPO |
$138.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: Wellcare Medicare |
$12.88
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dengue Fever Antibodies IgG, IgM
|
Professional
|
$184.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
4392804
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna Commercial |
$174.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Medicare Advantage |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.88
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$92.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.88
|
| Rate for Payer: Health EOS Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.88
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: Preferred Network Access Commercial |
$174.80
|
| Rate for Payer: Quartz Beloit One Network |
$80.96
|
| Rate for Payer: Quartz Commercial |
$104.88
|
| Rate for Payer: Quartz Medicare Advantage |
$12.88
|
| Rate for Payer: The Alliance Commercial |
$50.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.88
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$56.67
|
|
|
Dengue Fever Antibodies IgG, IgM
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
4392804
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Dengue Virus RNA, Real-Time PCR
|
Professional
|
$214.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4392627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$203.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$194.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: Preferred Network Access Commercial |
$203.30
|
| Rate for Payer: Quartz Beloit One Network |
$94.16
|
| Rate for Payer: Quartz Commercial |
$121.98
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$138.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$154.40
|
|
|
Dengue Virus RNA, Real-Time PCR
|
Facility
OP
|
$214.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4392627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Dengue Virus RNA, Real-Time PCR
|
Facility
IP
|
$214.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4392627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
IP
|
$25,271.00
|
|
|
Service Code
|
MS-DRG 158
|
| Min. Negotiated Rate |
$9,090.41 |
| Max. Negotiated Rate |
$25,271.00 |
| Rate for Payer: Aetna Managed Medicare |
$9,090.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,721.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,116.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,361.32
|
| Rate for Payer: Anthem Medicare Advantage |
$9,090.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,090.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,090.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,090.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,942.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,090.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,300.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,090.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,090.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,090.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,090.41
|
| Rate for Payer: NAPHCARE Commercial |
$13,635.62
|
| Rate for Payer: Quartz Medicare Advantage |
$9,090.41
|
| Rate for Payer: The Alliance Commercial |
$25,271.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,090.41
|
| Rate for Payer: United Healthcare PPO |
$14,247.37
|
| Rate for Payer: Wellcare Medicare |
$9,090.41
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
IP
|
$45,703.00
|
|
|
Service Code
|
MS-DRG 157
|
| Min. Negotiated Rate |
$16,439.80 |
| Max. Negotiated Rate |
$45,703.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,439.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,875.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,498.51
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,125.38
|
| Rate for Payer: Anthem Medicare Advantage |
$16,439.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,439.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,439.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,439.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,001.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,439.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33,286.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,439.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,439.80
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,439.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,439.80
|
| Rate for Payer: NAPHCARE Commercial |
$24,659.70
|
| Rate for Payer: Quartz Medicare Advantage |
$16,439.80
|
| Rate for Payer: The Alliance Commercial |
$45,703.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,439.80
|
| Rate for Payer: United Healthcare PPO |
$25,913.97
|
| Rate for Payer: Wellcare Medicare |
$16,439.80
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
IP
|
$18,271.00
|
|
|
Service Code
|
MS-DRG 159
|
| Min. Negotiated Rate |
$6,572.41 |
| Max. Negotiated Rate |
$18,271.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,572.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,266.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,935.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,389.04
|
| Rate for Payer: Anthem Medicare Advantage |
$6,572.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,572.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,572.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,572.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,532.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,572.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,166.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,572.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,572.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,572.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,572.41
|
| Rate for Payer: NAPHCARE Commercial |
$9,858.62
|
| Rate for Payer: Quartz Medicare Advantage |
$6,572.41
|
| Rate for Payer: The Alliance Commercial |
$18,271.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,572.41
|
| Rate for Payer: United Healthcare PPO |
$10,250.21
|
| Rate for Payer: Wellcare Medicare |
$6,572.41
|
|
|
DENTAL RELATED PROCEDURE, EMERGENT CARE
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2950464
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
DENTAL RELATED PROCEDURE, EMERGENT CARE
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2950464
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Dental Varnish
|
Professional
|
$29.00
|
|
|
Service Code
|
CPT D1208
|
| Hospital Charge Code |
2572837
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.40
|
| Rate for Payer: Health EOS Commercial |
$26.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.66
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: Preferred Network Access Commercial |
$27.55
|
| Rate for Payer: Quartz Beloit One Network |
$12.76
|
| Rate for Payer: Quartz Commercial |
$16.53
|
| Rate for Payer: The Alliance Commercial |
$14.50
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
DENTISTRY, OPERATIVE
|
Facility
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
DENTISTRY, OPERATIVE
|
Facility
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
Deoxycorticosterone
|
Professional
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.98 |
| Max. Negotiated Rate |
$429.40 |
| Rate for Payer: Aetna Commercial |
$429.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Aetna Managed Medicare |
$30.98
|
| Rate for Payer: Anthem Medicare Advantage |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.98
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$429.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.98
|
| Rate for Payer: Health EOS Commercial |
$411.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.98
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$429.40
|
| Rate for Payer: Quartz Beloit One Network |
$198.88
|
| Rate for Payer: Quartz Commercial |
$257.64
|
| Rate for Payer: Quartz Medicare Advantage |
$30.98
|
| Rate for Payer: The Alliance Commercial |
$122.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.98
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$136.31
|
|
